Clinical Process Trainer (with Active USRN License) | EXL Pasay

Basic Function

The role is primarily responsible for designing and delivering Blue Cross Blue Shield of Minnesota classes to produce fully equipped, non-clinical and clinical resources to allow-them to successfully fulfill their role. The job focuses in providing training session on Utilization Management platform processes and procedures.

Essential Functions

Conducts comprehensive Intake training on receiving, researching, prioritizing and responding to Utilization Management, (UM) requests Case Management, Disease Management through mailbox management, system work queue management, incoming telephonic and written pre-service, post-service (pended claim), and concurrent care requests.Supervises outbound calls to providers and facilities as warranted, and to receive and route inbound calls from members, providers, customer service, or other internal stakeholders per Intake process.Monitors and evaluates an outstanding level of customer service throughout all points of customer contact.Ensure that the appropriate clinical staff receives the call, or written request in a timely manner and according to established practices, workflow processes, and departmental needs.Accurately apply specific guidelines, policies, and procedures as authorized by the clinical review areas. Ensures application of clinical experience, health plan benefit structure and claims payment knowledge to pre- service by facilitating gathering relevant and comprehensive clinical data through multiple sources.Monitors review of both medical documentation and claims data to assure appropriate resource utilization, identification of opportunities for Case Management, identify issues which can be used for education of network providers, identification and resolution of quality issues and inappropriate claim submission.Provides guidance on reviewing and identifying issues related to professional and facility provider claims data including determining appropriateness of code submission, analysis of the claim rejection and the proper action to complete the retrospective review with the goal of proper and timely payment to provider and member satisfaction.Provides guidance in identifying potential discrepancies in provider billing practices and intervenes for resolution and education with Provider Relations, or if necessary, involving Special Investigation Unit.

Performance Parameters

Quality and accuracy of deliverablesEfficiency and effectiveness (result-orientation)Training deliveryAdherence to internal standardsInteraction with the clients/ customer at an appropriate level to ensure high levels of client satisfactionEmployee satisfaction, people development and moraleGood performance on any other function that may occur from time to time or as directed by the SupervisorBuilds and maintains atmosphere where coaching, counseling, and feedback are considered essential for better performanceRisk recognition, assessment, analyses, management and mitigationDemonstration of in-depth knowledge and application of various methodologies in relevant situations or phases

Skills

Technical Skills

Above average knowledge of MS Office applications like – PowerPoint, MS Word and MS ExcelInternet usage and email accessLocal RN LicensingNursing educationProject managementProcess Specific SkillsTraining module developmentAbility to present the information in simple and easy to understand mannerAbility to understand and comprehend quickly about unfamiliar industryPrioritizing customer needsStrong customer service focus

Soft Skills (Minimum)

Above average verbal and written communication skillsAbove average presentation skillsFlexibility and urgency to handle pressureTeam work/ Self-sufficiency / AdaptabilitySelf-disciplined and results orientedData gathering ability/ Keen eye for detailAnalytical skillsOperational planning and process managementAbility to multi task Ability to approach problems logicallyInterpersonal SkillsCustomer Service FocusCoaching and mentoring skills 

Soft skills (Desired)

Project managementBasic domain knowledge

Education Requirements

Non-Clinical: College graduateClinical: Graduate with at least 14 years of education with degree in Nursing and with active USRN license

Work Experience Requirements

USRN Trainer – At least 1 year clinical + 2 years of HC experienceNon-Clinical Trainer – At least 2 year HC experience